American Indian Veterans' Views about Their Choices in Health Care: VA, IHS, and Medicare

Reifel, Nancy; Bayhylle, Ruth; Harada, Nancy; Villa, Valentine

American Indian Culture and Research Journal, v33 n3 p23-33 2009

Legislation during the past three decades has gradually drawn Indian Health Service (IHS)-funded clinics into the mainstream of the US medical care environment. The Indian Self-Determination and Education Reform Act of 1973 and its Indian Education Amendments of 1984 began a movement away from federal management of health services to local tribal control of the more than five hundred facilities serving American Indians. At the same time the Indian Health Care Improvement Act granted authority to IHS-funded clinics to bill Medicaid, beginning a long and continuing negotiation among the tribes, states, IHS, and Centers for Medicare and Medicaid Services (CMS). In 1990, 6% (72,000 individuals) of IHS beneficiaries were more than sixty-five and eligible for Medicare. Some 31.6% lived below the poverty level and were eligible for Medicaid. By 2008, 18% of the IHS budget is assumed to be met by third-party collections, including CMS billing. The Alaska Native and American Indian Direct Reimbursement Act of 1999 gave tribal clinics the authority to bill Medicaid directly for services without using the IHS as an intermediary, thus further facilitating access to CMS programs. An alternative view of the changing landscape of IHS funding is that the number of American Indian people who use both IHS-funded health services and CMS programs is growing; they are joining the ranks of millions of Americans who receive services from more than one government health care program. In 2001, 45% of veterans were over age sixty-five and eligible for both Medicare and Veterans Administration (VA) health care. An individual's simultaneous use of more than one health care system presents problems in the management of chronic disease, confusion about the definition of medical necessity, duplication of services, and higher costs. Conversely, those who have access to more than one system of care may benefit from the greater diversity of services offered. In February 2003 the VA and IHS entered into an agreement committing the agencies to cooperation and resource sharing. As these efforts move forward, medical care systems need to evaluate carefully how and why people use multiple systems for care. The Native American Project of the Veteran Identity Program (VIP) was designed to explore health system, personal, and cultural characteristics that influence access to VA health services specifically among a Native American veteran population. This qualitative study provides data for a careful examination of how American Indian men, who have more than one choice for ambulatory health care services, select a provider for care. (Contains 1 table and 25 notes.)